I am writing this letter in regards to the new IMR process that was enacted with SB 863. I am a represented injured worker who has deep concerns about how I will be able to get medical records to the IMR.

This is my situation. My primary treating physician’s office charges me $35. to get my report. Since I cannot be copied on these reports I have no idea when they are actually written or sent to utilization review. I have a secondary doctor who is a pain management doctor, and their office policy is not to give reports to the injured worker. Again, I have no idea after my exam when the report will be transcribed or sent to utilization review. Both doctor’s offices cannot “cc” me on my reports, as I have requested. My attorney is very busy as well, so getting reports sent to me can be challenging. I do not have a complete file of my records. I would think most represented injured workers do not have copies of all their medical reports and testing's.

With the new IMR process there are strict deadlines for sending the request for IMR and the records accompanying them. I am aware that the requesting doctor, injured worker, applicant attorney and claims adjuster can send records. The temporary guidelines do state the claims adjuster must send the past 6 months of records. A study of the IMR reviews has shown that some claims adjusters are in fact not sending the records. This was reviewed by a judge who did not overturn those IMR denials even after it was found records were not sent. The claims adjuster also did not receive a fine for not sending the records. HOW could that happen as fines were listed against claims adjusters who do not send records to the IMR doctor? Now claims adjusters know they will not be penalized for not sending relevant records to the IMR, or any records. You now have a fox in the henhouse situation, with patient’s health at stake.

This is my question and concern. How is it a fair system for injured workers who are represented and do not have access to their medical records and/or do not receive them timely? I have heard of some applicant attorneys who are sending the records, however many are too busy. There is no such rule that state’s they have to. They also do not get paid to do so. I have discussed this with other injured workers and they are in the SAME situation as I am. Can the system be fair if we do not have access to our records if the claims adjuster does not have to follow the rules and send the records.

I am also concerned at the amount of records the guidelines state have to be sent. I have read it was one year, and then I read it was six months. For many injured workers, they have important testing’s that should be sent, that go beyond that date. For a spinal injury for example, we do not get MRI’s every six months, and sometimes past a year. For injured workers who have secondary conditions such as urological and testing’s such as urodynamic and cystoscopy may only be done once in a claim. That is not something can or should be done yearly. If that injured worker had those tests two years prior, which showed significant damage, the claims adjuster does not have to send them per the temporary rules. How would that IMR review be fair to the injured worker who desperately needed surgery to restore bladder function, but those records were not sent?

There is another problem with this new process that no one seems to be addressing. Many times the claims adjuster does not send the doctor’s request to UR in the first place. What does an injured worker do in that situation. He cannot even request an IMR until there is a UR denial. I am asking this as many of my doctor’s requests are not sent by my adjuster to UR, and not approved by her either. I have talked to other injured workers and this happens all the time to them too. One recently had their doctor request spinal surgery. The adjuster did not send it to UR, and did not approve it. I know very well that applicant attorneys are supposed to take non-compliant requests that were not sent to UR to an expedited hearing. From my own personal experience, and talking to many other injured workers that does not happen. Applicant Attorney’s cannot take all non-compliant UR issues to court. They do not have the time. I have had three attorneys and have not had one take that issue to court. I did not see any new penalties in SB 863 that addresses what happens when the claims adjuster refuses to send something to UR. If they do not change it to pre-SB 899 where applicant attorneys could get paid for taking these issues to court, I do not see this changing. If we expect them to work for peanuts and take all of these non compliant UR issues to court, they would soon go out of business.

I am also writing this for the countless injured workers who are not aware of their rights or the new IMR laws. I am aware that injured workers will receive notification of their rights to request an IMR after they receive a UR denial. I believe MOST injured workers in California are not aware of SB 863 and the complicated IMR process. Yes, it is one the state’s web-page however many injured workers either do not have access to that or even aware where that site is. I think the state should send out a booklet about the IMR process to all California injured workers giving a detailed explanation of how to request an IMR, their rights to send medical records and how to get access to their medical records. If they are not holding claims adjusters accountable for not sending records, they need to find a way to copy reports to represented injured workers, and send them a copy of past records.

The bottom line is an injured worker who is not represented will have to be copied on their doctor’s reports and testing’s and if they are aware of how the new IMR program works with being able to also submit records to the IMR reviewer they can defend them self’s since the claims adjuster will not always send the requested records for a proper IMR review. An injured worker who is represented has a hard time obtaining their medical records and when some claims adjusters are not following the law by sending the records (even after the IMR reviewing doctor had ask for them) there is little chance of getting the proper medical treatment authorized with a 65% denial rate going on with the IMR.If the State of California is going to also ask the injured worker to send records as well as the adjusters for the new IMR then all injured workers should by law also be copied as well as the adjusters and attorneys for the system to be fair and not one sided for the insurance companies.

It is Interesting to re-read this letter to you from an injured worker, and to compare it to the situation now. While there has been a few changes due to case law in regards to sending records, I still see many problems with the current IMR process, and agree with the above injured worker who wrote to you. This IMR process is not fair for California injured workers.

I view a few injured workers forums on occasion, and it is clear to me that many are not aware of how the UR or IMR system works. For those who are in this business it may seem simple, but I assure you it is not.

This is one example of what injured workers are writing on forums asking for help with constant denials. Notice no response.

I have tried to answer some of these questions on sites such as the above, to find many injured workers are not aware of the UR/IMR system, or not aware how to appeal a UR denial. They are not aware that they, their doctor or even their attorney can appeal a UR denial. Again, this is due to the system is much too complicated.

If the injured worker does not have a doctor who can appeal the UR denials effectively, their request will end up in IMR.That is IF the injured worker is aware of or applies for an IMR review. Many injured workers are not aware of how this complex system works. They are sent notices and do not always understand them. If they do not have an advocate such as a doctor or attorney who is looking out for them, they can fall into what the injured worker wrote about above which is denials for EVERYTHING their doctor requests. I have seen those with even catastrophic injuries fall into this.

I agree with the injured worker who wrote this letter to you above. This system is much too difficult for many injured workers to navigate. I hope that those who create such systems remember that injured workers come from all different backgrounds. Those who are most vulnerable and do not have an advocate helping them will become a victim of this system.

A little over a year later after this injured worker posted about UR and IMR concerns, the Dubon case is overturned. The letter written to you about injured workers not having access to their medical records, which would lead to unfair UR and IMR decisions is now happening to many injured workers. SB863 stated the claims adjuster will be responsible for proving records. The Dubon case states claims adjusters are not responsible for sending records and only late UR can be overturned.

Many PTP's do not have a complete file for the injured worker, and do not get paid for reviewing a file and do not have the time or resources to do it (especially for older claims with numerous records). I do not think applicant attorney's would have time to review and gather relevant medical records for all their clients UR denials and put together an appeal. Represented injured workers usually do not have their complete medical file. How is this system fair if relevant medical records are not being sent and in my opinion one of the main reasons for a UR denial, as it does not reflect previous testing's and treatments?

I posted a youtube video above that was sent to me from an injured worker (not the IW in the video). It is a video about a nurse who has an old California work related injury, however with Botox treatments and another medication she was able to return to work for 8 years. After SB 863 passed she has been put through the ringer and her treatments that kept her working were denied. She is currently not working and on state disability, due to her UR denial as her condition deteriorates without these treatments. The MTUS guidelines, chronic pain and surgery guidelines on the states web site do not cover all injuries, and especially the more complicated, co-morbid, chronic injuries.There are those patients who do not fit in the box that this system has created. I did read when doing an IMR you can use other guidelines outside of MTUS as long as they are medically recognized, unlike UR where you have to use MTUS. I hope this is something that was included in the new regulations, to give injured workers like the nurse in the above video a way to prove her treatment is necessary.

I agree with the injured worker above, the new IMR process is not fair to California injured workers, primarily because of this medical records issue, and secondary due to the guidelines do not reflect all injures... however I believe IMR we can use other guidelines for IMR.(unless that did not make it to the new regulations).

The video about the struggles that this injured nurse has gone through is unfortunately reflective of what many injured workers are currently going through. It saddens me to read about stories where a lack of medical treatment has caused them to be taken out of the workforce and now on disability.

Last edited by Barney5 on Thu Oct 09, 2014 11:30 am, edited 1 time in total.

An update from when I first wrote this letter to the editor, eight months ago I had a UR surgery denial, no proof of conservative treatment failure, the requesting physician did state all conservative treatment failed and listed those treatments that failed, the expert reviewer also included this statement in his narrative in his UR determination letter yet failed to request the missing records to prove conservative failure before denying this surgery.Here’s where the problem is, this surgeon was never given any records from the adjuster and limited records from my PTP, and I only had every tests report and film done in the long six years since the date of injury but not any records of conservative failure which are now years old, at least five years old.I did not do an IMR for 2 reasons, #1, Maximus rubber stamps the UR determination and #2, the claims adjuster is only required to give Maximus six months of records so proof of conservative failure will not be in those records because of their age and I did not have them to give to Maximus.Eight months later I got my hands on an old (2009) MMI report from my then PTP stating all conservative treatment has failed, a new updated MRI as well as an EMG/NCV test later and a new RFA for surgery and to my shock an approval for surgery this time.So because of the way this system is set up with SB863 there was an unnecessary delay in surgery, higher cost in more unnecessary test, more cost in continued doctor’s appointments and the possibility my condition could or could have become worse.I will add, the way I got my hands on this 2009 MMI report is by getting a disc from the WCAB of their records that I previously didn't know I can do, that's where I found this report.

If you are in pro per you can simply demand service of all medical reporting pursuant to CCR 10608 with a certified mail receipt and proof of service. If the insurance company/third party administator fails to serve the medicals you can then go to Med-Legal, LLC, who will subpoena the records on your behalf.

You can also seek sanctions and costs against the insurance carrier for failing to serve you the medical reporting. Injured workers do not need to pay for there medical reports, if they are not represented, they remain entitled to service of the reports.